Dolce Vita

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for one of two residents reviewed. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. Review of R1's medical record revealed a current written service plan dated November 24, 2023. This service plan indicated R1 received medication administration. 2. Review of R1's medical record revealed a signed medication order dated November 24, 2023. This medication order stated "Digoxin 0.125mg; Take 1 tab once a day; Hold if HR (heart rate) is less than 60". 3. Review of R1's medical record revealed a November 2023 medication administration record (MAR). This MAR stated "Digoxin 0.125mg take 1 tab once a day and hold if HR (heart rate) is less than 60". However, there was no documentation of the heart rate being taken prior to administration of the medication. 4. During an observation of R1's medications, Digoxin 0.125mg was observed. 5. In an interview, E1 reported the heart rate was taken prior to administration just not documented in the medical record.